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934 Septic Pumping Report 2010 Important: When filling out forms on the computer,use only the tab key to move your cursor-do not use the return key. 'Q /// -)b'L / t✓ ' 7 Commonweal oflvlassachusetts City/Town of/V? System Pumping Record Form 4 DEP has provided this form for use by local Boards of Health. Other forms may be used, but the information must be substantially the same as that provided here. Before using this form, check with your local Board of Health to determine the form they use.The System Pumping Record must be submitted to the local Board of Health or other approving authority within 14 days from the pumping date in accordance with 310 OMR 15.351. A. Facility Information System Location: Address City/Town 2. System Owner: • u su ;n ; 9 � { Na q7c( $pLn Q,iy Address(if different from Iota ion) t5farm4 dac•03/06 Zip Code City/Town State/3 i).—TV Telephone Number B. Pumping Record Na' IS/a 1540 1. Date of Pumping Date 2. Quantity Pumped: Gallons 3. Type of system: ❑ Cesspool(s) _I aeptic Tank ] Tight Tank ❑ Grease Trap ❑ Other(describe): 4. Effluent Tee Filter present? fl Yes 'INo If yes, was it cleaned Yes ❑ No 5. 6Co//n,ditio of System. 6. S sy teµ�yf�umped By. Name, /,` Company Location yvhere cggtents were disposed: p�1 ,S (Jt Vehicle License Number Signature of Hauler Date Signature of Receiving Facility Date System Pumping Record•Page 1 of 1